The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
ANS: 2
This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and pre-sents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.
You might also like to view...
The nurse is providing care to a client, with a history of rheumatoid arthritis (RA), who is 5 months pregnant. Which nursing actions are appropriate when providing care to this client? Select all that apply
A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy B) Monitoring the client for anemia due to salicylate therapy C) Suggesting the client begin supplemental pyridoxine D) Educating the client that medication therapy may be discontinued due to remission E) Teaching the client that RA may be contracted by the fetus during pregnancy
The ____________________ nurse is primarily responsible for keeping count of sponges, sharps, and instruments used during surgery
Fill in the blank(s) with correct word
A female patient is seen for "increased hoarseness" and a change in "voice quality.". There are no other symptoms. What is an appropriate assessment question for the nurse to ask this patient?
1. "What medications are you currently taking?" 2. "Have you recently experienced a cold?" 3. "Have you recently visited another country?" 4. "What is your occupation?"
Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
a. Perform dressing changes twice a day as ordered. b. Teach the patient about signs and symptoms of infection. c. Instruct the family about how to perform dressing changes. d. Gently refocus patient from discussing body image changes. e. Administer medications to control the patient's blood sugar as ordered.